Prevention of Future Deaths reports · 2021
Regulation 28 report to prevent future deaths, reference 2021-0208, written 18 Jun 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 18 Jun 2021 |
|---|---|
| Reference | 2021-0208 |
| Deceased | Lesley Mawby |
| Coroner | Lauren Costello |
| Coroner area | Manchester South |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. CHIEF EXECUTIVE STOCKPORT NHS FOUNDATION TRUST
1
CORONER
I am Lauren Costello, assistant coroner, for the coroner area of Manchester South
2
CORONER’S LEGAL POWERS
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
3
INVESTIGATION and INQUEST
On 7th October 2020 I commenced an investigation into the death of LESLEY
MAWBY then aged 73 years. The investigation concluded at the end of the
inquest on 21st May 2021. The narrative conclusion of the inquest was as follows:
Lesley Mawby died as a consequence of a recognised complication of
chemotherapy treatment on a background of frailty due to malnutrition where there
was a delay in commencing TPN Feeding.
The medical cause of death being
1a Multi-Organ Failure
1b
1c
Chemotherapy-Induced Bowel Toxicity
Multiple Myeloma
II Upper Gastrointestinal Haemorrhage, Gastritis, Sepsis
1
4
CIRCUMSTANCES OF THE DEATH
Lesley Mawby suffered from myeloma. She was diagnosed with asymptomatic myeloma
at the end of 2018. She remained symptom free until around April 2020 when she started
experiencing back pain. Following an MRI scan in July 2020 the decision was made to
start treating her Myeloma. She was treated with Lenalidomide and Dexamethasone and
began her first cycle of treatment in August 2020. On 19th August 2020 she began to
experience violent diarrhoea and vomiting and was admitted to Stepping Hill Hospital for
treatment. The vomiting and diarrhoea continued due to drug induced bowel toxicity. She
was unable to eat any food and her electrolytes became deranged. She was referred to
the dietetics department, but the assessment was delayed by a miscalculation of the
MUST Score and there were further delays in assessment by the dieticians due to staffing
levels. She was reviewed by a dietician on 1st September 2020 and nasogastric feeding
was started along with peripheral TPN on 2nd September 2020. Full TPN was started on
4th September 2020. Lesley had lost a significant amount of weight by this stage. Lesley
had an atypical response to TPN and it was not possible to bring Lesley’s electrolytes and
nutrition under control despite TPN and electrolyte replacement. In addition, she suffered
from sepsis, upper gastrointestinal hemorrhage and she continued to deteriorate. She
died on 5th October 2020 at Stepping Hill Hospital, Popular Grove, Hazel Grove Stockport
of multi organ failure as a result of chemotherapy induced bowel toxicity which was caused
by necessary treatment for multiple myeloma.
5
CORONER’S CONCERNS
During the course of the inquest the evidence revealed matters giving rise to concern. In
my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.
The MATTERS OF CONCERN are as follows. –
(1) It is a matter of concern that there are residual staffing shortages in the dietetic
team leading to delays in assessments on weekdays and meaning weekend cover
cannot be provided.
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you and
your organisation have the power to take such action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 13th August 2021. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out
the timetable for action. Otherwise you must explain why no action is proposed.
2
8
COPIES and PUBLICATION
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons
I am also copying this report to Stockport Clinical Commissioning Group and the Care
Quality Commission who I believe may find it useful or of interest.
I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it useful
or of interest.
You may make representations to me, the coroner, at the time of your response, about
the release or the publication of your response.
9
DATE
SIGNED BY CORONER
18th June 2021
3
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
FIRST CLASS MAIL PRIVATE AND CONFIDENTIAL HM Coroner (Manchester South) Coroner's Court 1 Mount Tabor Street Stockport SK13AG Stockport NHS Foundation Trust , · Oak House Stepping Hill Hospital Poplar Grove · Stockport Cheshire SK2 7JE 23 July 2021 Regulation 28 Report Lesley Mawby Dear Ms. Costello, I am writing further to the inquest of Lesley Mawby, which concluded on the 21 May 2021, and the Regulation 28: Report to Prevent Future Deaths and the matter of concern as follows: It is a matter of concern that there are residua! staffing shortages in the Dietetic team leading to delays in assessments on weekdays and meaning weekend cover cannot be provided. · I am grateful to you for providing me with the opportunity to respond to your concerns. I asked the Divisional Director of the Divison of Integrated Care to provide me with the information requested which I trust is satisfactory to you. Over the past 3 years the Dietetic Service has seen a significant increase in dem,ind on the service and staffing establishment has not been enhanced in line with this need. The increase in demand and requirement to increase staffing establishment has been recognised and actions are in place to address this issue, .as outlined below. Twice daily triage There is twice daily triage by a senior dietitian. All referrals for new patients are triaged by the Dietitians and. prioritised according to the dietetic referral triaging criteria, The 'Inpatient ward referral triage criteria' (Appendix A}, details the target times for reviewing referred patients in line with priority category. However, the Dietitians review all referrals in full and use clinical judgement to review a patient sooner if necessary. 7 day provision The service is not commissioned to run over 7 days and this is in line with other Greater Manchester NHS Trusts. The target times for reviewing patients operates in line with priority categories. However, there is weekend provision currently in place in the form of out of hours guidance, available for all staff, which includes feeding regimes for patients on enteral feeding or parenteral feeding: this supports appropriate nutrition being available over weekends ensuring no delays. A copy is attached in Appendix B and C .. The subsequent Your Health. Our Priority. dietetic review would then tailor the regime if necessary, but the regimes set in the guidance ensure that adequate nutrition would be received. Improved process A new streamlined process has been implemented, where staff add the referrals to a . spreadsheet with 'assessment due date' documented based on assessment criteria. This new process allows staff to filter the data easily and has improved ways of working. Patients already seen and requiring follow up remain on the spreadsheet with a 'review date' documented and reason for review. The Dietitian will review the highest priority patients from new and follow up patients and allocate those patients in order based on the criteria and clinical judgement to the staff available. The process is overseen by a senior Dietitian. Business Case developed Therapies Staffing A risk assessment in respect to the dietetic staffing was completed in October 2020 and a detailed review has been completed. The risk to patients due to the staffing establishment and capacity in the team is reviewed monthly by the divisional team and by the executives at the Risk Management Committee. A business case for therapy staffing is under development and is progressing through the Trust governance process. The Business Case is for increased support for therapy provision regarding nutrition and dietetics. It provides an option appraisal with a phased implementation of both qualified and non-qualified workforce, identifying high risk areas and allowing for training opportunities. However, the Trust has recognised the need for additional resource and is already recruiting to the posts. We would be happy to update you on progress in the future, if required. Job planning and benchmarking There is a dietitian job planning exercise underway with Project Management Office (PMO) support, due for completion in September 2021. This will be benchmarked against the British Dietetic Association (BOA) Dietetic Caseload Recommendations. The service is also participating in an NHS benchmarking exercise. A task and finish group has been set up to review processes and identify improvements. In addition, the service is benchmarking the referral process with other Greater Manchester trusts and there is an ongoing review of ward care plans /referral criteria. The current skill mix is also in the process of review with the . roles and responsibilities of non-registered staff being examined. · Additional measures implemented by the Dietetic Service to mitigate the risk are as follows: • • • • • The staffing establishment for community and acute nutrition and dietetic teams have been combined to work flexibly across both services. The specialist acute caseloads have been combined and will be prioritised accordingly across the service. Caseload management monitored regularly to ensure patients are prioritised and seen in a timely manner. Recruitment is underway to fill the current vacancies and these are being advertised both internally and externally. Interviews will be held in July 2021. A gap analysis has been completed and current gap in skillset identified. Training of substantive staff is to be arranged. Incident reporting The Dietetic Service has recognised that it is not always able to meet the target times to review patients that it sets itself due to the increase in demand. Incidents are reported via the Trust's incident reporting system (Datix), when patients are not reviewed within the timeframe specified at triage. The incidents are reviewed weekly at the Incident Review Page 2 Group, chaired by the Deputy Director of Quality Governance. The actions detailed above aim to reduce the risk of incidents occurring. We hope that the above addresses your concerns and assures you that the Trust has taken this matter of highest importance and put adequate actions in place. Please do not hesitate to contact me if you require any further information. Yours faithfully ~cu0. Chief Executive Enclosed: Appendix A: Inpatient Dietitians Referral Criteria and Triage Guidelines Appendix B: Parenteral Nutrition Out of Hours Regimen U_sing Triomel N4-700E Appendix C: Enteral: Out of hours starter tube feed regimen for adults Page 3 Appendix A: Inpatient Dietitian Department Inpatient Dietitians Referral Criteria and Triage Guidelines: September 2020 Referrals for inpatients to Dietetics are currently received from both Patient Centre and Advantis ward. The standardisation of one referral pathway is ongoing. Referrals received through these systems will be triaged and a priority assigned based .on the inforrnation on the referral. Referrals which do not meet the inclusion criteria will be declined and information of the reason for decline sent to the referring ward. Inpatient Dietitians currently provide a service Monday-Friday 8.00am-4.30pm; triaging will occur daily on these days at 8.30am and 1.00pm. Referrals received between these times will be triaged and prioritised in the following session. NB: Referral received for enteral feeding or parenteral feeding after 1.30pm, especially if Friday or prior to bank holiday, should be accommodated if staffing allows depending on time received and requirements. At a weekend, the out of hours generic detailed Dietician guidance and feeding regimes are recommended for use. 1. Criteria for referral: 1. 1 Inclusion criteria for referral to Inpatient Dietitians • Nutrition support for patients with a Malnutrition Universal Screening Tool (MUST) score 2: 2 • Enteral feeding (including Nasogastric, Nasojejunal, Ga"strostomy, Jejunostomy, distal) • Parenteral feeding (TPN) • High stoma output • Renal diet • • Diabetes • Newly diagnosed coeliac disease • • Oesophageal Stent and dietary advice • Pressure ulcers category 2 or above Liver disease Liquid diet 1.2 Exclusion criteria • Weight reduction/management or Obesity • • Low Albumin · MUST score O or 1 (ward will be informed to follow Trust Nutritional_ care plan) 2. Prioritisation and standards re new assessment: The priorities assigned will be priority .1, priority 2 and priority 3. The standards for new assessment from receipt to referral are: Priority 1: 1 working day from receipt of referral 8.30am or 1.30pm (triage takes place twice daily) • Parenteral Nutrition • Enteral Nutrition • MUST score of 6 • Liquid diet Priority 2: 2 working days from receipt of referral • Eating disorders • Oesophageal stent • Liver disease • High output stoma Priority 3: 3 working days from receipt of referral • MUST score 2: 2 • Renal diet • Diabetes • Newly diagnosed coeliac disease • Pressure ulcers category 2 or above Appendix B Parenteral Nutrition Out of Hours Regimen Using Triomel N4-700E · Please only use the Parenteral Nutrition Out of Hours Regimen where dietetic (or NST) cover is unavailable for more than 24 hours (usually From Friday afternoon to Sunday afternoon or Monday afternoon on bank holidays). Where the patient can be seen by dietetics (or the NST) within 24 hours please commence fluids and refer to dietetics (or NST) • Please send a referral to dietetics (via Patient Centre) for a tailored regimen to meet the patient's nutritional requirements • Prescribe Pabrinex (vials 1 +2) once daily for 3 days. The first pair dose should be given before parenteral nutrition is commenced with at least a 30 minute rest period between this finishing and the start of parenteral nutrition. • Baseline blood biochemistry should be checked before parenteral nutrition is started (U+E's, LFT's, phosphate, magnesium, glucose, lipids and CRP). • The parenteral nutrition solution (Triomel N4) should be prescribed either on ePMA or the drug kardex by the medical team or nurse clinician. Please use the table below for suggested volumes and flow rates. • Monitor biochemistry (U+E's, phosphate, magnesium, glucose) on a daily basis and correct low electrolyte levels as required. Monitor other bloods as outlined in the Parenteral Nutrition Policy • Other IV fluids may need to be adjusted as parenteral nutrition volumes are increased. • Consider monitoring cardiac rhythm in malnourished patients, or those with pre-existing arrhythmia Patient's Body Weiaht 25-29kg Day 1 [Triomel N4-700E] Day 2 [Triomel N4-700E] Day 3 [Triomel N4-700E] 192mls at Bmls/hr x 24 hrs 288mls at 12mls/hr x24hrs 384mls at 16mls/hr x24hrs 30-34kg 228mls at 9.5mls/hr x24hrs 348mls at 14.5mls/hr x24hrs 456mls at 19mls/hr x24hrs . 35-39kg 264mls at 11.0mls/hr x24hrs 396mls at 16.5mls/ x24hrs 528mls at 22mls/hr x24hrs. 40-49kg 324mls at 13.5mls/hr x24hrs 480mls at 20mls/hr x24hrs 636mls at 26.5mls/hr x24hrs . 50-59kg 384mls at 16mls/hr x24hrs 588mls at 24.5mls/hr x24hrs 780mls at 32.5mls/hr x24hrs 60-69kg 456mls at 19mls/hr x24hrs 696mls at 29mls/hr x24hrs 924mls at 38.5mls/hr x24hrs 70-79kg 528mls at 22mls/hr x24hrs 792mls at 33mls/hr x24hrs 1068mls at 44.5mls/hr x24hrs 80-89kg 600mls at 25mls/hr x24hrs 912mls at 38mls/hr x24hrs 1200mls at 50mls/hr x24hrs 90-99kg 672mls at 28mls/hr x24hrs 1008mls at 42mls/hr x24hrs 1344mls at 56mls/hr x24hrs 100kg and above 720mls at 30mls/hr x24hrs 1068mls at 44.5mls/hr x24hrs 1428mls at 59.5mls/hr x24hrs Using 5kcals/kg for mid- .p.oint weight Using 7.5kcals/kg for mid- point weight Using 10.0kcals/kg for mid- point weight A 2500mls bag contains 1750 (total) kcals, 62.5g protein, 52.5mmols sodium, 40mmols potassium, 5.5mmols magnesium, 5.0mmols calcium, 21.2mmols phosphate. Patients will receive proportionally lower doses of these nutrients as the parenteral nutrition regime is established Note: Patients are likely to require additional fluid with supplementary potassium due to low parenteral nutrition volumes at this early stage (June 2016) Issue date: August 2018 Version 2.3 Appendix C '•'l:kj Stockport NHS Foundation Trust Ensure nasogastric tube position is checked with pH indicator paper !>efore each use. A documented pH of S 5.5 confirms the tube is in the stomach1 2 3 4 • • • •. Refer to the trust Standard Operating Procedure for the Care and Management of Nasogastric Tubes in Adults. Please also see references overleaf for more information. ENTERAL: OUT OF HOURS STARTER TUBE FEED REGIMEN FOR ADULTS Only for use when dietetic service NOT available: Out of hours (weekends, bank holidays and after 4.30pm weekdays). For use during the. first 2-3 days of tube feeding only. Not suitable for use after this period. Process: 1. Seek senior medical approval before inserting a nasogastric tube and/or starting tube feed. 2. Please send a referral to Dietetics (via Patient Centre or Advantis Ward). 3. Refer to trust "Protocol for Re-feeding syndrome in Adults" located in Nutrition Microsite to identify if patient is at risk and follow guidelines prior to feed starting. 4. Medical team to please advise on additional fluids (IV or water via NGT) to maintain hydration. Volume may need to be adjusted as enteral feed volumes increase. Deliver no more than 150- 200ml per flush. 5. Monitor blood glucose levels at baseline then 1-2 times a day (or more if needed) until stable. Once stable monitor blood glucose weekly. Patient's Body Weiaht 25-29kq 30-39ka 40-49ka. 50-59kq 60-69ka 70-79ka 80-89kq 90ka and above Day1 Jevity 6mls/hour x 20 hours 8mls/hour x 20 hours 10mls/hour x 20 hours 13mls/hour x 20 hours 15mls/hour x 20 hours 17mls/hour x 20 hour.s 20mls/hour x 20 hours 22mls/hour x 20 hours Using 5kcals/kg for mid- point weight Day 2 Jevity Day3 Jevitv 13mls/hour x 20 hours 16mls/hour x 20 hours 21 mls/hour x 20 hours 26mls/hour x 20hours 30mls/ hour x 20 hours 35mls/hour x 20 hours 39mls/hour x 20 hours 44mls/hour x 20 hours Using 1 0.0kcals/kg for mid- point weight 19mls/hour x 20 hours 24mls/hour x 20 hours 31 mls/hour x 20hours 38mls/hour x 20 hours 45mls/hour x 20hours 52mls/hour x 20 hours 59mls/hour x 20 hours 63mls/ hour x 20 hours Using 15.0kcals/kg for mid-point weight Rest from feed for 4 hours per day For reference: 100ml of Jevity provides 107kcals, 4g protein,4mmol sodium, 4mmol potassium, 0.9mmol magnesium, 2.3mmol phosphate. Ensure medications are reviewed. by doctor and pharmacist to avoid drug nutrient interactions. · E.g.Warfarin or phenytoin: Feed needs to be stopped 2 hours pre and postphenytoin dose. Feed needs to be stopped 1 hour before and 2 hours after warfarin dose. If patient has diabetes - Please initiate 4 hourly blood glucose monitoring. Contact medical team, diabetes specialist nurses and dietitians if any concerns. If patient is not known to have diabetes - Please monitor blood glucose levels x2/day for 7 days. Check at random times during feed period. If consistently 4-8mmol/l then weekly blood glucose checks thereafter. If consistently out of this range, contact medical team, diabetes specialist nurses and dietitians if any concerns. ENTERAL FEE.DING GUIDELINES Setting up feeds • Check correct feed as per regimen and feed is within use by date • Wash hands according to hand washing guidelines • Set up feed in a clean area • Avoid unnecessary handling of feed/equipment • Do not touch the foil seal or tip of giving set • If decanting feeds into flexitainers use disposable foil cutters (single use item) and discard . after use. If decanting cans of feed, swab top and side of can with an alcohol wipe before pouring into flexitaine.rs. • Storage of feeds If using cans or bottles, as may occur.when bolus feeding, opened feeds should be stored in the fridge in a covered container (date+ time labelled). Discard any remaining feed after 24 hours. If bolus feeding with a giving set, store opened feed and giving set as a complete unit and keep in fridge for no more than 24 hours. Ensure the cap is closed on the giving set Feeds should be removed from the fridge up to 30 minutes before administering to adjust to room temperature. Hanging times Ready to hang feeds should not be hung for more than 24 hours. Please liaise with dietitian before decanting feeds. Flushing Flush tube with 50mls sterile water before and after feeding using the feeding port, after gastric aspiration, and after administration of all drugs using a 50ml syringe Please note that hospital syringes are single use only. If additional flushes are req·uired use the side port of the giving set Discarding/stopping feeds Throw away any unused feed and change giving set and bottles every 24 hours. When enteral feeding is no longer required please ensure that the pump is cleaned according to feeding and decontamination guidelines and that a decontamination certificate is completed before returning the pump and certificate to your ward pump store. Positioning The patient should be positioned at 30-40° whilst feeding wherever po$Sible, to decrease the risk of pulmonary aspiration. References 1) National Patient Safety Agency. Reducing harm caused by the misplacement of nasogastric feeding tubes. 2005 www.nrls.npsa.nhs.uk/resources/type/alerts/?entryid45-59794&p-4 2) NHS Improvement - Patient Safety Alert 2016 Nasogastric tube misp/acement:con/inuing risk of death and severe harm. · 3) https://improvement.nhs.uk/documents/194/Patient Safety Alert Stage 2 - NG tube resource set pdf 4) National Patient Safety Agency Reducing the harm caused by misplaced nasogastric feeding tubes in adults,children and infants 2011 www. nrls. npsa. n hs. u k/resourses/type/alerts/?entryid45-129640 5) National Patient Safety Agency Rapid Response Report: Harm from flushing of nasogastric tubes before confirmation of placement 2012 www. n rls. npsa. n hs. uk/resourses/type/alerts/?entryid45-133441
t.!1:b1 Stockport Clinical Commissioning Group 4th Floor Stopford House Piccadilly Stockport SK1 3XE www.stockportccg.nhs.uk Ek. 12 AUG 2021 HM CORONER MANCHESTER SOUTH 11 August 2021 Private & Confidential Ms Lauren Costello H M Assistant Coroner Coroner's Court 1 Mount Tabor Street Stockport SKl 3AG Dear Ms Costello Regulation 28 - Ms Lesley Mawby I refer to your letter dated 18 June in relation to the above and thank you for copying NHS Stockport Clinical Commissioning Group (CCG) into your communication with Stockport NHS Foundation Trust (Stepping Hill Hospital). I am sorry to learn of the death of Ms Mawby and offer my sincere condolences to her family. As the commissioner of healthcare services for the Stockport population I have reviewed the response provided by Stockport NHS Foundation Trust and I am satisfied that the actions taken are appropriate, will improve the service provided and reduce the likelihood of contributing to any future deaths. In addition to the steps taken and in order to support the Trust in the delivery of this service, I have requested a commissioning led review so that I can be assured that service levels can be consistently delivered. I hope the above is acceptable but if you require any further information in relation to this service then please do contact me via the following e mail address:- Yours sincerely Dr Medical Director . ) '•
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